Prediction of long-term prognosis in 12 169 men referred for cardiac rehabilitation

Machine Learning-Based Prediction Models for Healthcare Outcomes in Patients Participating in Cardiac Rehabilitation: A Systematic Review

PURPOSE

Cardiac rehabilitation (CR) has been proven to reduce mortality and morbidity in patients with cardiovascular disease. Machine learning (ML) techniques are increasingly used to predict healthcare outcomes in various fields of medicine including CR. This systemic review aims to perform critical appraisal of existing ML-based prognosis predictive model within CR and identify key research gaps in this area.

REVIEW METHODS

A systematic literature search was conducted in Scopus, PubMed, Web of Science, and Google Scholar from the inception of each database to January 28, 2024. The data extracted included clinical features, predicted outcomes, model development, and validation as well as model performance metrics. Included studies underwent quality assessments using the IJMEDI and Prediction Model Risk of Bias Assessment Tool checklist.

SUMMARY

A total of 22 ML-based clinical models from 7 studies across multiple phases of CR were included. Most models were developed using smaller patient cohorts from 41 to 227, with one exception involving 2280 patients. The prediction objectives ranged from patient intention to initiate CR to graduate from outpatient CR along with interval physiological and psychological progression in CR. The best-performing ML models reported area under the receiver operating characteristics curve between 0.82 and 0.91, with sensitivity from 0.77 to 0.95, indicating good prediction capabilities. However, none of them underwent calibration or external validation. Most studies raised concerns about bias. Readiness of these models for implementation into practice is questionable. External validation of existing models and development of new models with robust methodology based on larger populations and targeting diverse clinical outcomes in CR are needed.

Endurance Training Exercise Dose in Coronary Artery Disease Rehabilitation

Clinical management of patients with atherosclerotic coronary artery disease (CAD) following acute coronary syndrome includes cardiac rehabilitation. The well-established hallmark of cardiac rehabilitation is structured aerobic exercise training. To date, however, a limited number of studies have directly compared the effects of different doses of exercise on cardiovascular health, leaving uncertainty about the possible differential benefits of different exercise doses for use during cardiac rehabilitation. To address this area of uncertainty, we conducted a literature review and comparative analyses of studies that both compared two or more exercise interventions and assessed pre- and post-intervention peak oxygen consumption (V˙O2PEAK). Results from these analyses suggest that high exercise intensity, even when performed over relatively short duration interventions, appears to yield the most substantial improvements in cardiorespiratory fitness. However, this conclusion is based on the limited number of available studies, underscoring the need for future work examining exercise dose and clinical outcomes in the cardiac rehabilitation setting.

Children with cancer and their cardiorespiratory fitness and physical function-the long-term effects of a physical activity program during treatment: a multicenter non-randomized controlled trial

PURPOSE

We aimed to determine the effects of a classmate-supported, supervised, in-hospital physical activity program during treatment primarily on cardiorespiratory fitness and secondarily on physical function.

METHODS

A multicenter non-randomized controlled intervention study including children diagnosed with cancer, 6-18 years at diagnosis treated with chemo-/radiotherapy. The intervention comprised (i) an educational session on cancer in the child's school class; (ii) selection of two "ambassadors"-classmates who were co-admitted, supporting the child's everyday hospital life; and (iii) supervised in-hospital physical activity from diagnosis and throughout intensive treatment. One-year post-treatment, physical testing included cardiorespiratory fitness (primary outcome), Sit-to-Stand test, Timed-Up-and-Go, and Handgrip Strength.

RESULTS

The intervention group included 75 of 120 children (61% boys, 13.4 ± 3.1 years); the control groups included 33 of 58 children with cancer (58% boys, 13.5 ± 2.5 years), and 94 age- and sex-matched children without a cancer history. One-year post-treatment, cardiorespiratory fitness tended to be higher in the intervention group (37.0 ± 6.0 mL/kg/min) than in the patient control group with cancer (32.3 ± 9.7 mL/kg/min) (mean difference 4.7 [0.4 to 9.1], p = 0.034). The intervention group performed better in the secondary outcomes. Compared with community controls, both patient groups had lower cardiorespiratory fitness. The patient control group had lower Sit-to-Stand, Timed Up and Go, and Handgrip Strength, while the intervention group had strength comparable to that of the community controls.

CONCLUSIONS

Peer-supported, supervised, in-hospital physical activity during treatment may improve cardiorespiratory fitness and muscle strength 1-year post-treatment in children with cancer; however, survivors continue to have lower cardiorespiratory fitness than community controls.

IMPLICATIONS FOR CANCER SURVIVORS

Children with cancer may benefit from in-hospital physical activity in improving long-term cardiorespiratory fitness and muscle strength.

Impact of exercise-based cardiac rehabilitation on cardiopulmonary function and prognosis in ST elevation myocardial infarction after PCI patients in extremely cold regions

PURPOSE

To evaluate the impact of exercise-based cardiac rehabilitation (CR) on the cardiopulmonary function and prognosis in post-percutaneous coronary intervention (PCI) patients with ST elevation myocardial infarction (STEMI) in extremely cold regions of China.

METHODS

This retrospective study included 2,162 patients diagnosed with STEMI who were treated at five medical centers in extremely cold regions of China, between January 2020 and December 2023. All included patients underwent emergency coronary angiography and PCI. Based on whether they received exercise-based CR, patients were divided into a CR group and a non-CR group. To adjust for variations in initial risk factors and baseline characteristics between patients who underwent CR or not, we employed the propensity score matching. Each patient was matched in a 1:1 ratio with replacement. Patients who either participated in CR or did not, but could not be adequately matched, were excluded from the study population. Patient information between the two groups was systematically compared in hospital and at follow-up.

RESULTS

The rate of heart failure, re-hospitalization, and ventricular arrhythmia in CR group was significantly lower than that in non-CR group. The left ventricular ejection fraction (LVEF) measured by echocardiography in CR group were significantly higher than those in non-CR group. The cardiopulmonary test indicators for patients in CR group showed significant improvement over one year, including Power, HR, VCO₂, VO₂, VE, VD/VT, PetCO₂, CHO, CO, and SV, all with statistical significance. Multivariate COX regression analysis showed that CR was independently associated with heart failure in follow up.

CONCLUSION

Exercise-based CR effectively improves the recovery of cardiac function and prognosis in post-PCI patients with STEMI in extremely cold regions of China.

Impact of Different Low-Volume Concurrent Training Regimens on Cardiometabolic Health, Inflammation, and Fitness in Obese Metabolic Syndrome Patients

BACKGROUND/OBJECTIVES

Evidence supports the benefits of concurrent training (CT), which combines endurance and resistance exercises, for enhancing health and physical fitness. Recently, low-volume, time-efficient exercise approaches such as low-volume high-intensity interval training (LOW-HIIT), whole-body electromyostimulation (WB-EMS), and single-set resistance training (1-RT) have gained popularity for their feasibility and efficacy in improving various health outcomes. This study investigated the effects of low-volume CT, focusing on (1) whether exercise order affects cardiometabolic health, inflammation, and fitness adaptations and (2) which combination, LOW-HIIT plus WB-EMS or LOW-HIIT plus 1-RT, yields better results.

METHODS

Ninety-three obese metabolic syndrome (MetS) patients undergoing caloric restriction were randomly assigned to four groups performing the different low-volume CT protocols over 12 weeks. Outcomes included cardiometabolic, inflammatory, and fitness parameters.

RESULTS

In both combinations, no significant differences were found regarding exercise order. However, the pooled LOW-HIIT and 1-RT group achieved superior improvements in blood pressure, blood lipids, inflammation markers (CRP, hsCRP), the MetS severity score, and overall fitness compared to the LOW-HIIT and WB-EMS combination. Compared to previous studies using these modalities individually, LOW-HIIT plus 1-RT appeared to further reduce inflammation, whereas LOW-HIIT combined with WB-EMS was less effective for cardiometabolic health, potentially due to interference effects between modalities.

CONCLUSIONS

While LOW-HIIT plus WB-EMS appears to be a viable option for individuals unable to perform traditional resistance training, the findings suggest prioritizing LOW-HIIT plus 1-RT to maximize health outcomes. These findings highlight the importance of tailored exercise prescriptions and the need for further research into optimizing CT protocols for diverse populations.

Impact of cardiac rehabilitation exercise frequency on exercise capacity in patients with coronary artery disease: a retrospective study

Cardiac rehabilitation (CR) significantly improves cardiovascular outcomes in patients with coronary artery disease (CAD). International guidelines vary in the minimum recommended frequency of supervised exercise from 1 to 3 sessions per week. This is the first study in the Middle East and North African regions assessing the impact of 2 versus 3 days/week of supervised exercise on peak exercise capacity in patients with CAD. Single-center retrospective cohort study involving 362 patients enrolled in the only CR center in the State of Qatar. Only high-quality data was included by strict evaluation of compliance to the exercise intervention. Fifty patients who underwent a symptom-limited exercise test before and after CR were included (31 patients on 2 days/week, 19 on 3 days/week). No significant differences were observed in baseline characteristics between groups. Exercise intervention differed significantly between groups in exercise training frequency (2 days/week: 1.97 ± 0.2 vs. 3 days/week: 2.7 ± 0.3; p < 0.00). Peak exercise capacity as peak metabolic equivalents of task (MET) significantly increased in both groups (2 days/week: Pre 8.3 ± 2.4 vs. Post 9.4 ± 2.9, p-value 0.00; 3 days/week: Pre 7.4 ± 1.6 vs. Post 8.4 ± 2.0, p-value 0.00). No significant difference was observed between groups for change in Peak Exercise Capacity (2 days/week 1.1 ± 1.1 vs. 3 days/week 1.0 ± 0.9, p = 0.87). When the total number of exercise sessions is equal, supervised exercise frequencies of 2 and 3 days/week may significantly and equally improve peak exercise capacity in patients with CAD.

Survival of the fittest? Peak oxygen uptake and all-cause mortality among older adults in Norway

OBJECTIVE

To determine the cardiorespiratory fitness (CRF) levels needed to avoid the Grim Reaper (Death) among older adults. We hypothesized that an above average peak oxygen uptake (VO2peak) is needed for 70-77-year-old men and women to delay the encounter with Death.

DESIGN

Prospective cohort study.

SETTING

General population of older adults in Norway.

PARTICIPANTS

788 women and 777 men aged 70-77 years.

INTERVENTION

Clinical assessments, including a test of VO2peak. Participants were categorised based on their baseline VO2peak and changes after 1 year. This study explored associations between VO2peak and 5-year all-cause mortality using Cox proportional hazard models.

MAIN OUTCOME MEASURE

All-cause mortality.

RESULTS

Death caught up with 5.3 % of men and 3.7 % of women. Compared to unfit men and women, fewer men (Hazard Ratio [HR]: 0.34, 95 % Confidence Interval [CI] 0.15-0.78) and women (HR: 0.41, 95 % CI 0.17-0.98) classified as moderately fit encountered Death with no additional risk reduction among those classified as being more fit. It appears to be easier for the Grim Reaper to claim those in poorer physical condition, specifically VO2peak levels <26.5 mL/kg/min for men and 22.2 mL/kg/min for women (corresponding to ≥85 % of the observed age- and sex-specific average).

CONCLUSION

The Grim Reaper typically targets individuals with VO2peak levels <26.5 mL/kg/min/ and <22.2 mL/kg/min when chasing male and female souls aged 70-77 years, respectively, reflecting his penchant for limited CRF. These data underscore the importance of maintaining or enhancing CRF throughout life, providing clear targets for clinicians in assessing patient CRF levels.

TRIAL REGISTRATION

ClinicalTrials.govNCT01666340.

Effect of high-intensity intermittent rehabilitation training on physical function, gut microbiome and metabolite after percutaneous coronary intervention in patients with coronary heart disease

Background

Postoperative rehabilitation exercise training after percutaneous coronary intervention (PCI) is crucial for coronary heart disease (CHD) patients in restoring health and preventing recurrence, including high-intensity interval training (HIIT). However, the impact of HIIT on cardiopulmonary function, gut microbiome and metabolite remains underexplored.

Methods

This study included 60 patients with CHD who underwent percutaneous coronary intervention (PCI). Participants were divided into two groups: 33 in the moderate-intensity continuous training (MCT) group and 27 in the high-intensity interval training (HIIT) group. We assessed difference between two training in cardiopulmonary function, 6-minute walk test (6MWT) performance, biochemical indicators, plasma metabolites, and gut microbiome feature at baseline and after 3 months training. Furthermore, we analyzed 6MWT association to gut microbiome and metabolites with group differences.

Results

The 6MWT showed significantly greater improvement in the HIIT group compared to the MCT group (P = 0.0024). Both groups showed reductions in low-density lipoprotein (LDL) levels and increases in peak oxygen uptake (VO2 peak) after training, but the HIIT group demonstrated a larger effect size in these measures. Moreover, subgroup analysis revealed that patients with a history of myocardial infarction (MI) in the HIIT group experienced a more substantial increase in VO2 peak compared to the MCT group (P = 0.04). In addition, we identified 29 gut microbial species and 30 plasma metabolites that were differentially enriched between the two groups, with some showing a significant impact on 6MWT performance.

Conclusions

High-intensity interval training significantly improves 6MWT performance and exercise tolerance in cardiac rehabilitation patients, particularly enhancing VO2 peak in those with a history of MI. HIIT also appears to modulate the gut microbiome, increasing the abundance of Clostridiales and decreasing traumatic acid content, which may contribute to the observed improvements in exercise tolerance.

The Complementary Role of Cardiopulmonary Exercise Testing in Coronary Artery Disease: From Early Diagnosis to Tailored Management

Coronary artery disease (CAD) remains a leading cause of morbidity and mortality worldwide, accounting for over 9 million deaths annually. The prevalence of CAD continues to rise, driven by ageing and the increasing prevalence of risk factors such as hypertension, diabetes, and obesity. Current clinical guidelines emphasize the importance of functional tests in the diagnostic pathway, particularly for assessing the presence and severity of ischemia. While recommended tests are valuable, they may not fully capture the complex physiological responses to exercise or provide the necessary detail to tailor personalized treatment plans. Cardiopulmonary exercise testing (CPET) offers a comprehensive assessment of the cardiovascular, pulmonary, and muscular systems under stress, potentially addressing these gaps and providing a more precise understanding of CAD, particularly in settings where traditional diagnostics may be insufficient. By enabling more personalized and precise treatment strategies, CPET could play a central role in the future of CAD management. This narrative review examines the current evidence supporting the use of CPET in CAD diagnosis and management and explores the potential for integrating CPET into existing clinical guidelines, considering its diagnostic and prognostic capabilities, cost-effectiveness, and the challenges associated with its adoption.

Effectiveness of Home-Based Cardiac Rehabilitation with Optimized Exercise Prescriptions Using a Mobile Healthcare App in Patients with Acute Myocardial Infarction: A Randomized Controlled Trial

BACKGROUND

Despite the effectiveness of cardiac rehabilitation (CR), the actual participation rate in CR is low. While home-based CR offers a viable alternative, it faces challenges in participation due to factors such as a lack of self-motivation and fear of exercising without supervision. Utilizing a mobile healthcare application (app) during counseling may be an effective strategy for patients. Therefore, the aim of this study was to assess whether 6 weeks of home-based CR with exercise readjustment using a mobile app is an effective therapy for patients with acute myocardial infarction (AMI).

METHODS

Post-AMI patients eligible for home-based CR were randomized into the intervention group (CR-Mobile) and the control group, which followed the usual home-based CR protocol (CR-Usual). Both groups participated in a 6-week home-based CR program, with exercise readjustment and encouragement carried out every 2 weeks. The CR-Mobile group was supervised using data recorded in the mobile app, while the CR-Usual group was supervised via phone consultations. The primary outcome measured was maximal oxygen consumption (VO2max).

RESULTS

Within-group comparisons showed significant improvements in VO2max (PCR-Mobile = 0.011 vs. PCR-Usual = 0.020) and METs (PCR-Mobile = 0.011 vs. PCR-Usual = 0.011) for both groups.

CONCLUSIONS

These findings suggest that a 6-week home-based CR program with exercise readjustment using a mobile app can potentially enhance exercise capacity as effectively as verbal supervision.

Protein Supplementation Increases Adaptations to Low-Volume, Intra-Session Concurrent Training in Untrained Healthy Adults: A Double-Blind, Placebo-Controlled, Randomized Trial

Combined endurance and resistance training, also known as "concurrent training", is a common practice in exercise routines. While concurrent training offers the benefit of targeting both cardiovascular and muscular fitness, it imposes greater physiological demands on the body compared to performing each modality in isolation. Increased protein consumption has been suggested to support adaptations to concurrent training. However, the impact of protein supplementation on responses to low-volume concurrent training is still unclear. Forty-four untrained, healthy individuals (27 ± 6 years) performed two sessions/week of low-volume high-intensity interval training on cycle ergometers followed by five machine-based resistance training exercises for 8 weeks. Volunteers randomly received (double-blinded) 40 g of whey-based protein (PRO group) or an isocaloric placebo (maltodextrin, PLA group) after each session. Maximal oxygen consumption (VO2max) and overall fitness scores (computed from volunteers' VO2max and one-repetition maximum scores, 1-RM) significantly increased in both groups. The PRO group showed significantly improved 1-RM in all major muscle groups, while the PLA group only improved 1-RM in chest and upper back muscles. Improvements in 1-RM in leg muscles were significantly greater in the PRO group versus the PLA group. In conclusion, our results indicate that adaptations to low-volume concurrent training, particularly leg muscle strength, can be improved with targeted post-exercise protein supplementation in untrained healthy individuals.

Validity of the Ekblom-Bak Cycle Ergometer Test in Patients with Cardiovascular Disease

OBJECTIVE

To assess the validity of the Ekblom-Bak cycle ergometer test in patients with cardiovascular disease admitted to cardiac rehabilitation.

METHODS

Estimated peak oxygen consumption from the Ekblom-Bak test was compared with directly measured peak oxygen consumption from a treadmill cardiopulmonary exercise test. Patients completed the cardiopulmonary exercise test first, followed by the Ekblom-Bak test after 24 h rest. Pearson's correlation coefficient (r) was used to establish the correlation between estimated and measured peak oxygen consumption, and Bland-Altman plots with limits of agreement were used to determine the bias between the 2 tests.

RESULTS

Twenty-six patients were included in the final analysis. The Ekblom-Bak test significantly overestimated peak oxygen consumption. Agreement between estimated and measured peak oxygen consumption was: bias = 4.3 mL/kg/min (limits of agreement: -4.0-12.6 mL/kg/min).

CONCLUSION

The Ekblom-Bak test overestimated peak oxygen consumption to such an extent that it cannot accurately assess cardiorespiratory fitness in patients with cardiovascular disease. Thus, the cardiopulmonary exercise test remains the test of choice.

Applying Exercise Capacity and Physical Activity as Single vs Composite Endpoints for Trials of Cardiac Rehabilitation Interventions: Rationale, Use-case, and a Blueprint Method for Sample Size Calculation

OBJECTIVE

To conceptualize a composite primary endpoint for parallel-group RCTs of exercise-based cardiac rehabilitation (CR) interventions and to explore its application and statistical efficiency.

DESIGN

We conducted a statistical exploration of sample size requirements. We combined exercise capacity and physical activity for the composite endpoint (CE), both being directly related to reduced premature mortality in patients with cardiac diseases. Based on smallest detectable and minimal clinically important changes (change in exercise capacity of 15 W and change in physical activity of 10 min/day), the CE combines 2 dichotomous endpoints (achieved/not achieved). To examine statistical efficiency, we compared sample size requirements based on the CE to single endpoints using data from 2 completed CR trials.

SETTING

Cardiac rehabilitation phase III.

PARTICIPANTS

Patients in cardiac rehabilitation.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE(S)

Exercise capacity (Pmax assessed by incremental cycle ergometry) and physical activity (daily minutes of moderate to vigorous physical activity assessed by accelerometry).

RESULTS

Expecting, for example, a 10% between-group difference and improvement in the clinical outcome, the CE would increase sample size by up to 21% or 61%, depending on the dataset. When expecting a 10% difference and designing an intervention with the aim of non-deterioration, the CE would allow to reduce the sample size by up to 55% or 70%.

CONCLUSIONS

Trialists may consider the utility of the CE for future studies in exercise-based CR to reduce sample size requirements. However, perhaps surprisingly at first, the CE could also lead to an increased sample size needed, depending on the observed baseline proportions in the trial population and the aim of the intervention.

Exploring the effects of real-time online cardiac telerehabilitation using wearable devices compared to gym-based cardiac exercise in people with a recent myocardial infarction: a randomised controlled trial

Background

Exercise-based cardiac rehabilitation (CR) is a non-pharmacological multidisciplinary programme for individuals after myocardial infarction (MI) that offers multiple health benefits. One of the greatest barriers to CR participation is the travel distance to the rehabilitation centre. Remotely monitored CR appears to be at least as effective in improving cardiovascular risk factors and exercise capacity as traditional centre-based CR. Nevertheless, the efficacy of remotely monitored CR in individuals with a recent MI has yet to be examined.

Methods

A total of 30 individuals (8 women, 22 men) after a recent (i.e., <4 weeks) MI were randomly allocated into two groups (online home-based and gym-based groups). Both groups underwent a 26-week CR programme three times per week. All patients performed baseline and 24-week follow-up measurements where peak oxygen uptake (VO2peak), mean daily steps, distance, and calories were assessed.

Results

The online group showed an improvement in mean daily steps (p < 0.05) and mean daily distance (p < 0.05) at 24 weeks compared to the gym-based group. The paired-sample t-test showed that all the assessed variables were statistically (p < 0.001) improved for both groups at 24 weeks. Pearson's r demonstrated positive correlations between VO2peak and mean daily distance (r = 0.375), and negative correlations between VO2peak and muscle (r = -0.523) and fat masses (r = -0.460). There were no exercise-induced adverse events during the study.

Conclusion

Our findings might indicate that a real-time online supervised CR exercise programme using wearable technology to monitor the haemodynamic responses in post-MI patients is equally effective as a gym-based exercise programme.

An Exercise Immune Fitness Test to Unravel Disease Mechanisms-A Proof-of-Concept Heart Failure Study

Background: Cardiorespiratory fitness positively correlates with longevity and immune health. Regular exercise may provide health benefits by reducing systemic inflammation. In chronic disease conditions, such as chronic heart failure and chronic fatigue syndrome, mechanistic links have been postulated between inflammation, muscle weakness, frailty, catabolic/anabolic imbalance, and aberrant chronic activation of immunity with monocyte upregulation. We hypothesize that (1) temporal changes in transcriptome profiles of peripheral blood mononuclear cells during strenuous acute bouts of exercise using cardiopulmonary exercise testing are present in adult subjects, (2) these temporal dynamic changes are different between healthy persons and heart failure patients and correlate with clinical exercise-parameters and (3) they portend prognostic information. Methods: In total, 16 Heart Failure (HF) patients and 4 healthy volunteers (HV) were included in our proof-of-concept study. All participants underwent upright bicycle cardiopulmonary exercise testing. Blood samples were collected at three time points (TP) (TP1: 30 min before, TP2: peak exercise, TP3: 1 h after peak exercise). We divided 20 participants into 3 clinically relevant groups of cardiorespiratory fitness, defined by peak VO2: HV (n = 4, VO2 ≥ 22 mL/kg/min), mild HF (HF1) (n = 7, 14 < VO2 < 22 mL/kg/min), and severe HF (HF2) (n = 9, VO2 ≤ 14 mL/kg/min). Results: Based on the statistical analysis with 20-100% restriction, FDR correction (p-value 0.05) and 2.0-fold change across the three time points (TP1, TP2, TP3) criteria, we obtained 11 differentially expressed genes (DEG). Out of these 11 genes, the median Gene Expression Profile value decreased from TP1 to TP2 in 10 genes. The only gene that did not follow this pattern was CCDC181. By performing 1-way ANOVA, we identified 8/11 genes in each of the two groups (HV versus HF) while 5 of the genes (TTC34, TMEM119, C19orf33, ID1, TKTL2) overlapped between the two groups. We found 265 genes which are differentially expressed between those who survived and those who died. Conclusions: From our proof-of-concept heart failure study, we conclude that gene expression correlates with VO2 peak in both healthy individuals and HF patients, potentially by regulating various physiological processes involved in oxygen uptake and utilization during exercise. Multi-omics profiling may help identify novel biomarkers for assessing exercise capacity and prognosis in HF patients, as well as potential targets for therapeutic intervention to improve VO2 peak and quality of life. We anticipate that our results will provide a novel metric for classifying immune health.

Characteristics and Outcomes of Cardiac Rehabilitation Patients With and Without Cancer: Insights From Western Sydney

AIM

Increased cardiovascular events are common in cancer survivors and contribute to an emerging cardio-oncology patient group requiring secondary prevention strategies including cardiac rehabilitation (CR). This study aimed to compare characteristics and outcomes for patients participating in CR with and without an existing cancer diagnosis.

METHOD

Observational cohort study including consecutive patients enrolled in a single-centre outpatient CR program in Western Sydney between 2018-2022. Clinical history, demographics and CR outcome data were collected as part of standard care at program enrolment and completion. Patients with and without a cancer diagnosis were compared at enrolment and outcomes were analysed in both groups.

RESULTS

A total of 1,792 patients enrolled in CR, 191 (11%) had a documented history of cancer; prostate (18%), skin (12%), colon (9%) and breast (8%) malignancies were most prevalent. The most common treatments were surgical resection (80%) and chemotherapy or radiotherapy (37%). Cardio-oncology patients were older (68.8±10.6 vs 59.8±13.7yrs, p<0.001), more likely female (33% vs 21%, p<0.001), born in Australia (46% vs 35%, p=0.004), non-partnered (34% vs 25%, p=0.002) and had a prior history of hypertension (65% vs 56%, p=0.010) or stroke (8% vs 5%, p=0.045). After adjusting for age and sex, the overall cohort improved their mean peak exercise capacity and waist circumference after CR, however there were no differences between groups. There were also no between-group differences for adherence and completion of CR program or any other cardiovascular risk factors. Sub-analyses revealed a clinically meaningful improvement in waist circumference for cancer patients with a history of radiation therapy and a blunted peak exercise capacity adaptation for those with a history of chemotherapy treatment.

CONCLUSIONS

Despite differences in demographic and clinical characteristics of CR patients with and without cancer, all patients showed significant and clinically relevant improvements in peak exercise capacity and waist circumference after CR. Results also highlighted potential associations between specific cancer treatments and changes in fitness outcomes, which warrants further evaluation.

Cardiac hemodynamics phenotypes and individual responses to training in coronary heart disease patients

BACKGROUND

In patients with coronary heart disease (CHD), individualized exercise training (ET) programs are strongly recommended to optimize peak oxygen uptake (V ̇ $$ \dot{\mathrm{V}} $$ O2peak) improvement and prognosis. However, the cardiac hemodynamic factors responsible for a positive response to training remain unclear. The aim of this study was to compare cardiac hemodynamic changes after an ET program in responder (R) versus non-responder (NR) CHD patients.

METHODS

A total of 72 CHD patients completed a 3-month ET program and were assessed by cycle ergometer cardiopulmonary exercise test (CPET:V ̇ $$ \dot{\mathrm{V}} $$ O2peak assessment) with impedance cardiography (ICG) for hemodynamic measurements before and after training. Cardiac hemodynamics (e.g., CO, CI, SV, ESV, EDV, and SVR) were measured by ICG during CPET. The R and NR groups were classified using the median change inV ̇ $$ \dot{\mathrm{V}} $$ O2peak (>the median for R and ≤the median for NR).

RESULTS

In the R group,V ̇ $$ \dot{\mathrm{V}} $$ O2peak (+17%, p < 0.001), CO, CI, SV, and HR increased by 17%, 17%, 13%, and 5%, respectively (p < 0.05) after the training program. In the NR group,V ̇ $$ \dot{\mathrm{V}} $$ O2peak, CO, CI, and SV increased by 0.5%, 5%, 8%, and 6%, respectively (p < 0.01). The SVR decreased in both groups (-19% in R and -11% in NR, p < 0.001).

CONCLUSION

Among CHD patients, the R group showed a better improvement in peak cardiac output via an increase in peak stroke volume and heart rate and a reduced systemic vascular resistance than the NR group. Different cardiac phenotype adaptations and clinical individual responses were identified in CHD patients according to the aerobic fitness responder's status.

Inherited physical capacity: Widening divergence from young to adult to old

Cardiorespiratory performance segregates into rat strains of inherited low- and high-capacity runners (LCRs and HCRs); during adulthood, this segregation remains stable, but widens in senescence and is followed by segregated function, health, and mortality. However, this segregation has not been investigated prior to adulthood. We, therefore, assessed cardiorespiratory performance and cardiac cell (cardiomyocyte) structure-function in 1- and 4-month-old LCRs and HCRs. Maximal oxygen uptake was 23% less in LCRs at 1-month compared to HCRs at 1-month, and 72% less at 4 months. Cardiomyocyte contractility was 37-56% decreased, and Ca2+ release was 34-62% decreased, in 1- and 4-month LCRs versus HCRs. This occurred because HCRs had improved contractility and Ca2+ release during maturation, whereas LCRs did not. In quiescent cardiomyocytes, LCRs displayed 180% and 297% more Ca2+ sparks and 91% and 38% more Ca2+ waves at 1 and 4 months versus HCRs. Cell sizes were not different between LCRs and HCRs, but LCRs showed reduced transverse-tubules versus HCRs, though no discrepant transverse-tubule generation occurred during maturation. In conclusion, LCRs show reduced scores for aerobic capacity and cardiomyocyte structure-function compared to HCRs and there is a widening divergence between LCRs and HCRs during juvenile to near-adult maturation.

Impairment of the adrenergic reserve associated with exercise intolerance in a murine model of heart failure with preserved ejection fraction

AIM

Exercise intolerance is the central symptom in patients with heart failure with preserved ejection fraction. In the present study, we investigated the adrenergic reserve both in vivo and in cardiomyocytes of a murine cardiometabolic HFpEF model.

METHODS

12-week-old male C57BL/6J mice were fed regular chow (control) or a high-fat diet and L-NAME (HFpEF) for 15 weeks. At 27 weeks, we performed (stress) echocardiography and exercise testing and measured the adrenergic reserve and its modulation by nitric oxide and reactive oxygen species in left ventricular cardiomyocytes.

RESULTS

HFpEF mice (preserved left ventricular ejection fraction, increased E/e', pulmonary congestion [wet lung weight/TL]) exhibited reduced exercise capacity and a reduction of stroke volume and cardiac output with adrenergic stress. In ventricular cardiomyocytes isolated from HFpEF mice, sarcomere shortening had a higher amplitude and faster relaxation compared to control animals. Increased shortening was caused by a shift of myofilament calcium sensitivity. With addition of isoproterenol, there were no differences in sarcomere function between HFpEF and control mice. This resulted in a reduced inotropic and lusitropic reserve in HFpEF cardiomyocytes. Preincubation with inhibitors of nitric oxide synthases or glutathione partially restored the adrenergic reserve in cardiomyocytes in HFpEF.

CONCLUSION

In this murine HFpEF model, the cardiac output reserve on adrenergic stimulation is impaired. In ventricular cardiomyocytes, we found a congruent loss of the adrenergic inotropic and lusitropic reserve. This was caused by increased contractility and faster relaxation at rest, partially mediated by nitro-oxidative signaling.

Aerobic exercise interventions for promoting cardiovascular health and mobility after stroke: a systematic review with Bayesian network meta-analysis

OBJECTIVE

To determine the superiority of aerobic exercise (AE) interventions on key outcomes of stroke recovery, including cardiorespiratory fitness (V̇O2peak, primary outcome), systolic blood pressure (SBP) and mobility (6 min Walk Test (6MWT) distance and 10 m Usual Gait Speed) after stroke.

DATA SOURCES

MEDLINE, EMBASE, Web of Science, CINAHL, CENTRAL, SPORTDiscus, PsycINFO and AMED Allied and Complementary Medicine were searched from inception to February 2023.

ELIGIBILITY CRITERIA

Randomised controlled trials were included that compared the effects of any AE interventions (low-intensity, moderate-intensity, high-intensity continuous training (HICT), high-intensity interval training (HIIT)) to no exercise, usual care or other AE interventions in individuals poststroke.

ANALYSES

Systematic review with Bayesian network meta-analysis (NMA) methodology was employed. Surface under the cumulative ranking curve (SUCRA) values were used to rank interventions. The Grading of Recommendations, Assessment, Development and Evaluation minimally contextualised framework for NMA was followed.

RESULTS

There were 28 studies (n=1298) included in the NMA for V̇O2peak, 11 (n=648) for SBP, 28 (n=1494) for 6MWT and 18 (n=775) for the 10 m Usual Gait Speed. The greatest effect on V̇O2peak, 6MWT and 10 m Usual Gait Speed was observed after HIIT and HICT. No differences between interventions were found for SBP. SUCRA values identified HIIT as the superior AE intervention for all outcomes of interest. HIIT was the most effective intervention for improving V̇O2peak (2.9 mL/kg/min (95% credible interval 0.8 to 5.0) moderate certainty) compared with usual care.

CONCLUSION

This NMA suggests that higher-intensity AE is superior to traditional low-intensity to moderate-intensity AE for improving outcomes after stroke.

Assessing cardiorespiratory fitness in clinical and community settings: Lessons and advancements in the 100th year anniversary of VO2max

Cardiorespiratory fitness (CRF) is a well-established biomarker that has applications to all adults across the health and disease spectrum. Despite overwhelming evidence supporting the prognostic utility of CRF, it remains vastly underutilized. CRF is optimally measured via cardiopulmonary exercise testing which may not be feasible to implement on a large scale. Therefore, it is prudent to develop ways to accurately estimate CRF that can be applied in clinical and community settings. As such, several prediction equations incorporating non-exercise information that is readily available from routine clinical encounters have been developed that provide an adequate reflection of CRF that could be implemented to raise awareness of the importance of CRF. Further, technological advances in smartphone apps and consumer-grade wearables have demonstrated promise to provide reasonable estimates of CRF that are widely available, which could enhance the utilization of CRF in both clinical and community settings.

Cardiorespiratory Fitness Benefits of Long-Term Maintenance-Phase Cardiac Rehabilitation in Males and Females: A Retrospective Cohort Study

Purpose

This study investigated if associations exist between enrolment delay and VO2peak over five years of maintenance-phase cardiac rehabilitation (CR) in males and females.

Method

Data were extracted from the records of participants who had enrolled for ≥ 1 year in CR and completed ≥ 2 cardiopulmonary exercise tests. Mixed model analyses examined VO2peak trajectories for up to five years of enrolment. Interactions between enrolment delay × enrolment duration, baseline age × enrolment duration, and baseline VO2peak × enrolment duration were explored for inclusion in the model.

Results

The charts of 151 males (aged 63.9 ± 9.4 y) and 32 females (aged 65.3 ± 9.0 y) were included in the analyses. The enrolment delay following a cardiovascular event was 1.8 ± 3.0 years for males and 1.3 ± 1.7 years for females. No associations were found between enrolment delay × enrolment duration on VO2peak in males (β[SEj, 0.07[0.05]; 95% CI -0.02, 0.16, p = 0.12) or in females (β[SE], 0.07[0.13j; 95% CI -0.18, 0.33, p = 0.57), but predicted trajectories suggest clinically significantly improvements in VO2 peak (range, 1.3 to 1.6 mL/kg/min).

Conclusions

Early enrolment in CR is recommended and encouraged, but the benefits of long-term CR are possible despite delays.

Hemodynamic Response to Exercise Training in Heart Failure With Reduced Ejection Fraction Patients

Background

Supervised exercise training decreases total and cardiac mortality and increases quality of life of heart failure with reduced ejection fraction (HFrEF) patients. However, response to training is variable from one patient to another and factors responsible for a positive response to training remain unclear. The aims of the study were to compare cardiac hemodynamic changes after an exercise training program in responders (R) versus non-responders (NR) HFrEF patients, and to compare different discriminators used to assess response to training.

Methods

Seventy-six HFrEF patients (86% males, 57 ± 12 years) completed an exercise training program for 4 weeks. Patients underwent cardiopulmonary exercise testing (CPET) on a cycle ergometer before and after training. Cardiac hemodynamics were measured by impedance cardiography during CPET. The R and NR groups were classified using the median change in peak oxygen uptake (V̇O2peak).

Results

There were statistically significant differences in V̇O2peak (+35% vs. -1%, P < 0.0001) and in peaks of ventilation (+30% vs. +2%, P < 0.0001), cardiac output (COpeak) (+25% vs. +4%, P < 0.01), systolic blood pressure (+12% vs. +2%, P < 0.05), diastolic blood pressure (+9% vs. +4%, P < 0.05) and heart rate (+8% vs. +1%, P < 0.01) between R and NR after the training program. V̇O2peak was the best discriminator between R and NR (receiver operating characteristic (ROC) area under the curve (AUC) = 0.83, P < 0.0001), followed by COpeak (ROC AUC = 0.77, P < 0.0001).

Conclusion

V̇O2peak is the best discriminator between HFrEF R and NR patients after the training program. Responders showed improvements in peak hemodynamic parameters. These results pave the way for other studies to determine how the individualization of exercise training programs and peak hemodynamic parameters potentially linked to a better positive response status.

Association between physical activity patterns of working-age adults and social jetlag, depressive symptoms, and presenteeism

OBJECTIVES

This study aimed to evaluate the association of physical activity with social jetlag, depressive symptoms, and presenteeism.

METHODS

This cross-sectional study included 8247 working-age adults (females, 44.6%; age, 20-64 years). Social jetlag was defined as the absolute difference between the midpoint of bedtime and wake time on workdays and free days. Depression symptoms were assessed using the Center for Epidemiologic Studies Depression Scale, and presenteeism was evaluated using the Work Functioning Impairment Scale. Exercise habits were classified into 4 groups based on the World Health Organization guidelines: nonactive (NA; n = 4223), insufficiently active (IA; n = 3009: exercise below guideline levels), weekend warriors (WW; n = 220: exercise 1-2 times per week meeting guideline levels), and regularly active (RA; n = 793: exercise at least 3 d/wk meeting guideline levels). Using multiple and Poisson regression analyses, we examined the association between exercise habits and each outcome.

RESULTS

Social jetlag, depression, and presenteeism were more favorable with shorter sedentary times and longer durations of moderate- and vigorous-intensity exercise. Compared with the RA group, the NA group had a significantly higher prevalence of social jetlag (prevalence ratio [PR] = 1.30), depression (PR = 1.31), and presenteeism (PR = 1.35). The IA group had a significantly higher prevalence of depression (PR = 1.33) and presenteeism (PR = 1.38).

CONCLUSIONS

Exercising with a certain frequency and intensity may help prevent symptoms of depression and social jetlag, and consequently prevent presenteeism.

Exercise-based cardiac rehabilitation in stable angina pectoris: a narrative review on current evidence and underlying physiological mechanisms

Stable angina pectoris (SAP) is a prevalent condition characterised by a high disease burden. Based on recent evidence, the need for revascularisation in addition to optimal medical treatment to reduce mortality and re-events is heavily debated. These observations may be explained by the fact that revascularisation is targeted at the local flow-limiting coronary artery lesion, while the aetiology of SAP relates to the systemic, inflammatory process of atherosclerosis, causing generalised vascular dysfunction throughout the entire vascular system. Moreover, cardiovascular events are not solely caused by obstructive plaques but are also associated with plaque burden and high-risk plaque features. Therefore, to reduce the risk of cardiovascular events and angina, and thereby improve quality of life, alternative therapeutic approaches to revascularisation should be considered, preferably targeting the cardiovascular system as a whole with a physiological approach. Exercise-based cardiac rehabilitation fits this description and is a promising strategy as a first-line treatment in addition to optimal medical treatment. In this review, we discuss the role of exercise-based cardiac rehabilitation in SAP in relation to the underlying physiological mechanisms, we summarise the existing evidence and highlight future directions.

Residential Greenness and Long-term Mortality Among Patients Who Underwent Coronary Artery Bypass Graft Surgery

BACKGROUND

Studies have reported inverse associations between exposure to residential greenness and mortality. Greenness has also been associated with better surgical recovery. However, studies have had small sample sizes and have been restricted to clinical settings. We investigated the association between exposure to residential greenness and all-cause mortality among a cohort of cardiac patients who underwent coronary artery bypass graft (CABG) surgery.

METHODS

We studied this cohort of 3,128 CABG patients between 2004 and 2009 at seven cardiothoracic departments in Israel and followed patients until death or 1st May 2021. We collected covariate information at the time of surgery and calculated the patient-level average normalized difference vegetation index (NDVI) over the entire follow-up in a 300 m buffer from the home address. We used Cox proportional hazards regression models to estimate associations between greenness and death, adjusting for age, sex, origin, socioeconomic status, type of hospital admission, peripherality, air pollution, and distance from the sea.

RESULTS

Mean age at surgery was 63.8 ± 10.6 for men and 69.5 ± 10.0 for women. During an average of 12.1 years of follow-up (37,912 person-years), 1,442 (46%) patients died. A fully adjusted Cox proportional hazards model estimated a 7% lower risk of mortality (HR: 0.93, 95% CI = [0.85, 1.00]) per 1 interquartile range width increase (0.04) in NDVI. Results were robust to the use of different buffer sizes (100 m-1,250 m from the home) and to the use of average NDVI exposure during the first versus the last 2 years of follow-up.

CONCLUSIONS

Residential greenness was associated with lower risk of mortality in CABG patients.

Feasibility of preoperative and postoperative physical rehabilitation for cardiac surgery patients - a longitudinal cohort study

BACKGROUND

This study aimed to determine the feasibility of a preoperative and postoperative (in- and outpatient) physical rehabilitation program, the Heart-ROCQ-pilot program.

METHODS

This cohort study included patients undergoing cardiac surgery (including coronary artery bypass graft surgery, valve surgery, aortic surgery, or combinations of these surgeries) and participated in the Heart-ROCQ-pilot program. Feasibility involved compliance and characteristics of bicycle and strength training sessions in the three rehabilitation phases.

RESULTS

Of the eligible patients, 56% (n = 74) participated in the program (41% of exclusions were due to various health reasons). On average across the rehabilitation phases, the compliance rates of bicycle and strength training were 88% and 83%, respectively. Workload to heart rate (W/HR) ratio and total absolute volume load for bicycle and strength training, respectively, improved in each rehabilitation phase (P < 0.05). The W/HR-ratio was higher during the last postoperative session compared to the first preoperative session (0.48 to 0.63 W/beat, P < 0.001) and similar to the last preoperative session (0.65 to 0.64 W/beat, P < 0.497). During less than 1% of the bicycle sessions, patients reported discomfort scores of 5 to 6 (scale 0-10, with higher scores indicating a higher level).

CONCLUSIONS

The Heart-ROCQ-pilot program was feasible for patients awaiting cardiac surgery. Patients were very compliant and were able to safely increase the training load before surgery and regained this improvement within eight weeks after surgery.

Effect of High-Intensity Interval Training and Moderate-Intensity Continuous Training in People With Poststroke Gait Dysfunction: A Randomized Clinical Trial

BACKGROUND

The exercise strategy that yields the greatest improvement in both cardiorespiratory fitness (V ̇ O 2 peak $$ \dot{\mathrm{V}}{\mathrm{O}}_{2\mathrm{peak}} $$ ) and walking capacity poststroke has not been determined. This study aimed to determine whether conventional moderate-intensity continuous training (MICT) or high-intensity interval training (HIIT) have different effects on V ̇ O 2 peak $$ \dot{\mathrm{V}}{\mathrm{O}}_{2\mathrm{peak}} $$ and 6-minute walk distance (6MWD).

METHODS AND RESULTS

In this 24-week superiority trial, people with poststroke gait dysfunction were randomized to MICT (5 days/week) or HIIT (3 days/week with 2 days/week of MICT). MICT trained to target intensity at the ventilatory anaerobic threshold. HIIT trained at the maximal tolerable treadmill speed/grade using a novel program of 2 work-to-recovery protocols: 30:60 and 120:180 seconds. V̇O2 and heart rate was measured during performance of the exercise that was prescribed at 8 and 24 weeks for treatment fidelity. Main outcomes were change in V ̇ O 2 peak $$ \dot{\mathrm{V}}{\mathrm{O}}_{2\mathrm{peak}} $$ and 6MWD. Assessors were blinded to the treatment group for V ̇ O 2 peak $$ \dot{\mathrm{V}}{\mathrm{O}}_{2\mathrm{peak}} $$ but not 6MWD. Secondary outcomes were change in ventilatory anaerobic threshold, cognition, gait-economy, 10-meter gait-velocity, balance, stair-climb performance, strength, and quality-of-life. Among 47 participants randomized to either MICT (n=23) or HIIT (n=24) (mean age, 62±11 years; 81% men), 96% completed training. In intention-to-treat analysis, change in V ̇ O 2 peak $$ \dot{\mathrm{V}}{\mathrm{O}}_{2\mathrm{peak}} $$ for MICT versus HIIT was 2.4±2.7 versus 5.7±3.1 mL·kg-1·min-1 (mean difference, 3.2 [95% CI, 1.5-4.8]; P<0.001), and change in 6MWD was 70.9±44.3 versus 83.4±53.6 m (mean difference, 12.5 [95% CI, -17 to 42]; P=0.401). HIIT had greater improvement in ventilatory anaerobic threshold (mean difference, 2.07 mL·kg-1·min-1 [95% CI, 0.59-3.6]; P=0.008). No other between-group differences were observed. During V̇O2 monitoring at 8 and 24 weeks, MICT reached 84±14% to 87±18% of V ̇ O 2 peak $$ \dot{\mathrm{V}}{\mathrm{O}}_{2\mathrm{peak}} $$ while HIIT reached 101±22% to 112±14% of V ̇ O 2 peak $$ \dot{\mathrm{V}}{\mathrm{O}}_{2\mathrm{peak}} $$ (during peak bouts).

CONCLUSIONS

HIIT resulted in more than a 2-fold greater and clinically important change in V ̇ O 2 peak $$ \dot{\mathrm{V}}{\mathrm{O}}_{2\mathrm{peak}} $$ than MICT. Training to target (ventilatory anaerobic threshold) during MICT resulted in ~3 times the minimal clinically important difference in 6MWD, which was similar to HIIT. These findings show proof of concept that HIIT yields greater improvements in cardiorespiratory fitness than conventional MICT in appropriately screened individuals.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT03006731.

Effect of Exercise Training on Peak Aerobic Power After Heart Transplantation: A Brief Review

Heart transplantation (HTP) is a life-saving therapy for selected individuals with end-stage refractory heart failure. Despite improvements in quality of life and survival, HTP recipients' peak aerobic power (peak VO2) remains up to 50% lower than age-matched healthy control subjects owing to abnormal cardiovascular and skeletal muscle function. Currently, little is known regarding the effect of exercise training (ET) to improve peak VO2 after HTP. This brief review aims to summarise existing evidence regarding the role of ET on peak VO2 and its determinants, highlights the upper limits of endurance performance in highly trained HTP athletes, and identifies areas for future HTP exercise rehabilitation research.

The evolving role of cardiopulmonary exercise testing in ischemic heart disease - state of the art review

PURPOSE OF REVIEW

Cardiopulmonary exercise testing (CPET) is the gold standard for directly assessing cardiorespiratory fitness (CRF) and has a relatively new and evolving role in evaluating atherosclerotic heart disease, particularly in detecting cardiac dysfunction caused by ischemic heart disease. The purpose of this review is to assess the current literature on the link between cardiovascular (CV) risk factors, cardiac dysfunction and CRF assessed by CPET.

RECENT FINDINGS

We summarize the basics of exercise physiology and the key determinants of CRF. Prognostically, several studies have been published relating directly measured CRF by CPET and outcomes allowing for more precise risk assessment. Diagnostically, this review describes in detail what is considered healthy and abnormal cardiac function assessed by CPET. New studies demonstrate that cardiac dysfunction on CPET is a common finding in asymptomatic individuals and is associated with CV risk factors and lower CRF. This review covers how key CPET parameters change as individuals transition from the asymptomatic to the symptomatic stage with progressively decreasing CRF. Finally, a supplement with case studies with long-term longitudinal data demonstrating how CPET can be used in daily clinical decision making is presented.

SUMMARY

In summary, CPET is a powerful tool to provide individualized CV risk assessment, monitor the effectiveness of therapeutic interventions, and provide meaningful feedback to help patients guide their path to improve CRF when routinely used in the outpatient setting.

Differential Effects of Very-Low-Volume Exercise Modalities on Telomere Length, Inflammation, and Cardiometabolic Health in Obese Metabolic Syndrome Patients: A Subanalysis from Two Randomized Controlled Trials

Oxidative stress (OS) and inflammation are features of metabolic syndrome (MetS) that can contribute to the shortening of telomere length (TL), a marker of cellular ageing. Research indicates that exercise can positively influence MetS-associated conditions and TL. However, the effects of low-volume exercise types on TL are still unknown. We investigated the impact of very-low-volume high-intensity interval training (LV-HIIT), one-set resistance training (1-RT), and whole-body electromyostimulation (WB-EMS) on TL, inflammation, and cardiometabolic indices in 167 MetS patients. Data were derived from two randomized controlled trials where patients were allocated to an exercise group (2 sessions/week, for 12 weeks) or a control group. All groups received standard-care nutritional weight loss counselling. TL was determined as the T/S ratio (telomere to single-copy gene amount). All groups significantly reduced body weight (p < 0.05), but the T/S-ratio (p < 0.001) only increased with LV-HIIT. OS-related inflammatory markers (C-reactive protein, interleukin-6, and lipopolysaccharide-binding protein) only decreased (p < 0.05) following LV-HIIT. The MetS severity z-score improved with LV-HIIT (p < 0.001) and 1-RT (p = 0.014) but not with WB-EMS. In conclusion, very-low-volume exercise modalities have differential effects on telomeres, inflammation, and cardiometabolic health. Only LV-HIIT but not strength-based low-volume exercise increased TL in MetS patients, presumably due to superior effects on OS-related inflammatory markers.

Protocol for Community-Based Exercise Training after Discharge from Hospital-Based Stroke Rehabilitation: A Multicenter, Randomized, Parallel-Group, Double-Blind Controlled Pilot and Feasibility Trial

Exercise training participation of patients with stroke in the community after discharge from the hospital has many benefits for physical, social, and psychological rehabilitation and improves their quality of life. However, in the Republic of Korea, studies on stroke survivors who can participate in an exercise training program have not been conducted. This trial aims to investigate the effectiveness of exercise training programs after patients with stroke are discharged from the hospital with a doctor's note and referred to a community exercise center, as there is a lack of studies on this population. This multicenter, randomized, parallel-group, double-blind controlled pilot and feasibility trial will randomly assign 120 patients with stroke to either 8 weeks of a community-based exercise training program (experimental group) or activities of daily living (control group). The primary outcomes will be muscle strength, cardiorespiratory fitness, body composition, physical performance, and gait. The secondary outcomes will be quality of life and activities of daily living. This study's results may add new insights into the effectiveness of community-based exercise training programs after patients with stroke are discharged from the hospital with a doctor's note and referred to a community exercise center. The success of the new exercise training approach could offer valuable information for developing more inclusive protocols for patients with stroke in the future if it proves to be efficacious.

Clinical challenges facing patient participation in cardiac rehabilitation: cigarette smoking

INTRODUCTION

Cardiac rehabilitation (CR) is highly effective at reducing morbidity and mortality. However, CR is underutilized, and adherence remains challenging. In no group is CR attendance more challenging than among patients who smoke. Despite being more likely to be referred to CR, they are less likely to enroll, and much more likely to drop out. CR programs generally do not optimally engage and treat those who smoke, but this population is critical to engage given the high-risk nature of continued smoking in those with cardiovascular disease.

AREAS COVERED

This review covers four areas relating to CR in those who smoke. First, we review the evidence of the association between smoking and lack of participation in CR. Second, we examine how smoking has historically been identified in this population and propose objective screening measures for all patients. Third, we discuss the optimal treatment of smoking within CR. Fourth, we review select populations within those who smoke (those with lower-socioeconomic status, females) that require additional research and attention.

EXPERT OPINION

Smoking poses a challenge on multiple fronts, being a significant predictor of future morbidity and mortality, as well as being strongly associated with not completing the secondary prevention program (CR) that could benefit those who smoke the most.

Comparison of telehealth and supervised phase III cardiac rehabilitation in regional Australia: protocol for a non-inferiority trial

INTRODUCTION

Exercise-based cardiac rehabilitation programmes (ExCRP) promote recovery and secondary prevention for individuals with cardiovascular disease (CVD). Despite this, enrolment and adherence to ExCRP in rural locations is low. Telehealth programmes provide a convenient, home-based intervention, but concerns remain about compliance to exercise prescription. This paper presents the rationale and protocol design to determine if telehealth delivered ExCRP is not inferior to supervised ExCRP for improving cardiovascular function and exercise fidelity.

METHOD AND ANALYSIS

A non-inferiority, parallel (1:1), single-blinded randomised clinical trial will be conducted. Fifty patients with CVD will be recruited from a rural phase II ExCRP. Participants will be randomly assigned to telehealth or supervised ExCRP and prescribed three weekly exercise sessions for 6 weeks. Exercise sessions will include a 10 min warm up, up to 30 min of continuous aerobic exercise at a workload equivalent to the ventilatory anaerobic threshold and a 10 min cool down. The primary outcome will be change in cardiorespiratory fitness as measured by cardiopulmonary exercise test. Secondary outcome measures will include change in blood lipid profile, heart rate variability, pulse wave velocity, actigraphy measured sleep quality and training fidelity. Non-inferiority will be confirmed if intention-to-treat and per-protocol analyses conclude the same outcome following independent samples t-test with p<0.025.

ETHICS AND DISSEMINATION

Research ethics committees at La Trobe University, St John of God Health Care and Bendigo Health approved the study protocol and informed consent. Findings will be published in peer-reviewed journals and disseminated among stakeholders.

TRIAL REGISTRATION NUMBER

ACTRN12622000872730p; pre-results.

Electrically assisted cycling for individuals with type 2 diabetes mellitus: a pilot randomized controlled trial

BACKGROUND

Type 2 diabetes mellitus (T2DM) and its associated complications puts considerable strain on healthcare systems. With the global incidence of T2DM increasing, effective disease management is essential. Physical activity (PA) is a key component of T2DM management; however, rates of PA engagement are low in this population. Developing effective and sustainable interventions that encourage PA is a high priority. Electrically assisted bicycles are becoming increasingly popular and may increase PA in healthy adults. This study aimed to provide evidence of the feasibility of conducting a randomized controlled trial to evaluate the efficacy of an e-cycling intervention to increase PA and improve health in individuals with T2DM.

METHODS

A parallel-group two-arm randomized, waitlist-controlled pilot study was conducted. Individuals were randomized to either an e-bike intervention or standard care. The intervention incorporated two one-to-one e-bike skills training and behavioural counselling sessions delivered by a community-based cycling charity, followed by a 12-week e-bike loan with two further sessions with the instructors. Feasibility was assessed via measures related to recruitment, retention and intervention implementation. Post-intervention interviews with instructors and participants explored the acceptability of the study procedures and intervention. Clinical, physiological and behavioural outcomes were collected at baseline and post-intervention to evaluate the intervention's potential.

RESULTS

Forty participants (M_age = 57) were randomized, of which 34 were recruited from primary care practices. Thirty-five participants were retained in the trial. The intervention was conducted with high fidelity (> 80% content delivered). E-bike training provided participants with the skills, knowledge and confidence needed to e-bike independently. Instructors reported being more confident delivering the skills training than behavioural counselling, despite acknowledging its importance. The study procedures were found to be acceptable to participants. Between-group differences in change during the intervention were indicative of the interventions potential for improving glucose control, health-related quality of life and cardiorespiratory fitness. Increases in overall device measured moderate-to-vigorous PA behaviour following the intervention were found, and there was evidence that this population self-selected to e-cycle at a moderate intensity.

CONCLUSIONS

The study's recruitment, retention, acceptability and potential efficacy support the development of a definitive trial subject to identified refinements.

TRIAL REGISTRATION

ISRCTN, ISRCTN67421464 . Registered 17/12/2018.

A Nonexercise Prediction of Peak Oxygen Uptake for Patients With Cardiovascular Disease: DATA FROM THE FITNESS REGISTRY AND THE IMPORTANCE OF EXERCISE INTERNATIONAL DATABASE (FRIEND)

PURPOSE

Nonexercise predictions of peak oxygen uptake (V˙ o2peak ) are used clinically, yet current equations were developed from cohorts of apparently healthy individuals and may not be applicable to individuals with cardiovascular disease (CVD). Our purpose was to develop a CVD-specific nonexercise prediction equation for V˙ o2peak .

METHODS

Participants were from the Fitness Registry and Importance of Exercise International Database (FRIEND) with a diagnosis of coronary artery bypass surgery (CABG), myocardial infarction (MI), percutaneous coronary intervention (PCI), or heart failure (HF) who met maximal effort criteria during a cardiopulmonary exercise test (n = 15 997; 83% male; age 63.1 ± 10.4 yr). The cohort was split into development (n = 12 798) and validation groups (n = 3199). The prediction equation was developed using regression analysis and compared with a previous equation developed on a healthy cohort.

RESULTS

Age, sex, height, weight, exercise mode, and CVD diagnosis were all significant predictors of V˙ o2peak . The regression equation was:V˙ o2peak (mL · kg -1 · min -1 ) = 16.18 - (0.22 × age [yr]) + (3.63 × sex [male = 1; female = 0]) + (0.14 × height [cm]) - (0.12 × weight [kg]) + (3.62 × mode [treadmill = 1; cycle = 0]) - (2.70 × CABG [yes = 1, no = 0]) - (0.31 × MI [yes = 1, no = 0]) + (0.37 × PCI [yes = 1, no = 0]) - (4.47 × HF [yes = 1, no = 0]). Adjusted R 2 = 0.43; SEE = 4.75 mL · kg -1 · min -1 .Compared with measured V˙ o2peak in the validation group, percent predicted V˙ o2peak was 141% for the healthy cohort equation and 100% for the CVD-specific equation.

CONCLUSIONS

The new equation for individuals with CVD had lower error between measured and predicted V˙ o2peak than the healthy cohort equation, suggesting population-specific equations are needed for predicting V˙ o2peak ; however, errors associated with nonexercise prediction equations suggest V˙ o2peak should be directly measured whenever feasible.

Maximum Heart Rate- and Lactate Threshold-Based Low-Volume High-Intensity Interval Training Prescriptions Provide Similar Health Benefits in Metabolic Syndrome Patients

Exercise is an integral part of metabolic syndrome (MetS) treatment. Recently, low-volume high-intensity interval training (LOW-HIIT) has emerged as a time-efficient approach to improving cardiometabolic health. Intensity prescriptions for LOW-HIIT are typically based on maximum heart rate (HR_max) percentages. However, HR_max determination requires maximal effort during exercise testing, which may not always be feasible/safe for MetS patients. This trial compared the effects of a 12-week LOW-HIIT program based on: (a) HR_max (HIIT-HR), or (b) submaximal lactate threshold (HIIT-LT), on cardiometabolic health and quality of life (QoL) in MetS patients. Seventy-five patients were randomized to HIIT-HR (5 × 1 min at 80-95% HR_max), HIIT-LT (5 × 1 min at 95-105% LT) groups, both performed twice weekly on cycle ergometers, or a control group (CON). All patients received nutritional weight loss consultation. All groups reduced their body weight (HIIT-HR: -3.9 kg, p < 0.001; HTT-LT: -5.6 kg, p < 0.001; CON: -2.6 kg, p = 0.003). The HIIT-HR and HIIT-LT groups similarly, improved their maximal oxygen uptake (+3.6 and +3.7 mL/kg/min, p < 0.001), glycohemoglobin (-0.2%, p = 0.005, and -0.3%, p < 0.001), homeostasis model assessment index (-1.3 units, p = 0.005, and -1.0 units, p = 0.014), MetS z-score (-1.9 and -2.5 units, p < 0.001) and QoL (+10 points, p = 0.029, and +11 points, p = 0.002), while the CON did not experience changes in these variables. We conclude that HIIT-LT is a viable alternative to HIIT-HR for patients who are not able/willing to undergo maximal exercise testing.

Physiological and mental health changes in cancer patients during the COVID-19 state of emergency

Backgrounds

Due to the COVID-19 pandemic that we are currently facing, many governments across the world have declared a state of emergency and even confinements. This stressful situation, in addition to prolonged stays at home, may imply a radical change in lifestyle behavior and physical activity (PA). The aim of this study is to evaluate the physiological and psychological effects in cancer patients who changed their PA habits during the COVID-19 state of emergency in Spain.

Methods

Thirty-three participants were evaluated pre- and post-state of emergency. A series of questionnaires was used to assess cancer-specific quality of life.

Results

The most relevant results revealed significantly lower walking time (p < 0.001) and sitting time (p = 0.014). Upper and lower body strength also decreased significantly (p = 0.009 and 0.012, respectively) and oxygen consumption (VO2 peak) (p = 0.023). None of the parameters analysed showed significant differences for psychological aspects (QLQ-C-30 and SF-36) and body composition.

Conclusion

Lower physical activity leads to negative physiological adaptation, particularly affecting cardiovascular and strength levels. While it is important to maintain the general population's amount and intensity of exercise, this particularly vulnerable group's physical capacity is vital to their health and well-being.

Effect of Resistance Training on Body Composition, Hemodynamic Parameters and Exercise Tolerance among Patients with Coronary Artery Disease: A Systematic Review

BACKGROUND

Effectiveness and safety of Resistance Training in treating various Cerebrovascular Disease diagnoses have drawn attention in recent years. Patients suffering with coronary artery disease should be offered individually tailored Resistance Training in their exercise regimen. Resistance Training was developed to help individuals with their functional status, mobility, physical performance, and muscle strength.

OBJECTIVE

The objective of this review was to collect, summarize and present information on the state of science focusing on usefulness, viability, safety and efficacy of Resistance Training in treating coronary artery disease and enhancing the aerobic capacity and improving overall health-related quality of life.

METHODS

The review is prepared in accordance with Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines. Searches were conducted in Cochrane Library, PubMed/MEDLINE, PEDro and Scopus database. PEDro scale was used for methodological quality assessment of included studies. Two independent reviewers determined the inclusion criteria of studies by classifying interventions based on core components, outcome measures, diagnostic population and rated the quality of evidence and strength of recommendations using GRADE criteria.

RESULTS

Total 13 studies with 1025 patients were included for the detailed analysis. Findings emphasize the importance of assessing effectiveness and safety of Resistance Training in individuals with coronary artery disease. Patient specific designed exercise programs as Resistance Training targets at enhancing patients' exercise tolerance, improves hemodynamic response and muscular strength with reduction in body fat composition.

CONCLUSION

Resistance Training is an effective exercise that should be incorporated to counteract the loss of muscle strength, muscle mass, and physiological vulnerability, as well as to combat the associated debilitating effects on physical functioning, mobility and overall independence and Quality of Life during rehabilitation of patients with coronary artery disease.

High-Intensity Interval Training is Safe, Feasible and Efficacious in Nonalcoholic Steatohepatitis: A Randomized Controlled Trial

BACKGROUND

High-Intensity Interval Training (HIIT) involves bursts of high-intensity exercise interspersed with lower-intensity exercise recovery. HIIT may benefit cardiometabolic health in people with nonalcoholic steatohepatitis (NASH).

AIMS

We aimed to examine the safety, feasibility, and efficacy of 12-weeks of supervised HIIT compared with a sham-exercise control (CON) for improving aerobic fitness and peripheral insulin sensitivity in biopsy-proven NASH.

METHODS

Participants based in the community [(n = 14, 56 ± 10 years, BMI 39.2 ± 6.7 kg/m², 64% male), NAFLD Activity Score 5 (range 3-7)] were randomized to 12-weeks of supervised HIIT (n = 8, 4 × 4 min at 85-95% maximal heart rate, interspersed with 3 min active recovery; 3 days/week) or CON (n = 6, stretching; 3 days/week). Safety (adverse events) and feasibility determined as ≥ 70% program completion and ≥ 70% global adherence (including session attendance, interval intensity adherence, and duration adherence) were assessed. Changes in cardiorespiratory fitness (V̇O₂peak), exercise capacity (time-on-test) and peripheral insulin sensitivity (euglycemic hyperinsulinemic clamp) were assessed. Data were analysed using ANCOVA with baseline value as the covariate.

RESULTS

There were no HIIT-related adverse events and HIIT was globally feasible [program completion 75%, global adherence 100% (including adherence to session 95.4 ± 7.3%, interval intensity 95.3 ± 6.0% and duration 96.8 ± 2.4%)]. A large between-group effect was observed for exercise capacity [mean difference 134.2 s (95% CI 19.8, 248.6 s), ƞ² 0.44, p = 0.03], improving in HIIT (106.2 ± 97.5 s) but not CON (- 33.4 ± 43.3 s), and for peripheral insulin sensitivity [mean difference 3.4 mg/KgLegFFM/min (95% CI 0.9,6.8 mg/KgLegFFM/min), ƞ² 0.32, p = 0.046], improving in HIIT (1.0 ± 0.8 mg/KgLegFFM/min) but not CON (- 3.1 ± 1.2 mg/KgLegFFM/min).

CONCLUSIONS

HIIT is safe, feasible and efficacious for improving exercise capacity and peripheral insulin sensitivity in people with NASH.

CLINICAL TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trial Registry (anzctr.org.au) identifier ACTRN12616000305426 (09/03/2016).

Physical activity, cardiorespiratory fitness, and cardiovascular health: A clinical practice statement of the American Society for Preventive Cardiology Part II: Physical activity, cardiorespiratory fitness, minimum and goal intensities for exercise training, prescriptive methods, and special patient populations

The prescription of exercise for individuals with and without cardiovascular disease (CVD) should be scientifically-based yet adapted to the patient. This scientific statement reviews the clinical and physiologic basis for the prescription of exercise, with specific reference to the volume of physical activity (PA) and level of cardiorespiratory fitness (CRF) that confer significant and optimal cardioprotective benefits. Recommendations are provided regarding the appropriate intensity, frequency, and duration of training; the concept of MET-minutes per week; critical components of the exercise session (warm-up, conditioning phase, cool-down); methodologies for establishing the training intensity, including oxygen uptake reserve (V̇O2R), target heart rate derivation and rating perceived exertion; minimum and goal intensities for exercise training; and, types of training activities, including resistance training, adjunctive lifestyle PA, marathon/triathlon training, and high-intensity interval training. In addition, we discuss the rationale for and value of exercise training programs for patients with peripheral artery disease, diabetes mellitus, and heart failure.

Cardiopulmonary exercise testing and impedance cardiography in the assessment of exercise capacity of patients with coronary artery disease early after myocardial revascularization

Background

Patients with coronary artery disease (CAD) are characterized by different levels of physical capacity, which depends not only on the anatomical advancement of atherosclerosis, but also on the individual cardiovascular hemodynamic response to exercise. The aim of this study was evaluating the relationship between parameters of exercise capacity assessed via cardiopulmonary exercise testing (CPET) and impedance cardiography (ICG) hemodynamics in patients with CAD.

Methods

Exercise capacity was assessed in 54 patients with CAD (41 men, aged 59.5 ± 8.6 years) within 6 weeks after revascularization by means of oxygen uptake (VO2), assessed via CPET, and hemodynamic parameters [heart rate (HR), stroke volume, cardiac output (CO), left cardiac work index (LCWi)], measured by ICG. Correlations between these parameters at anaerobic threshold (AT) and at the peak of exercise as well as their changes (Δpeak–rest, Δpeak–AT) were evaluated.

Results

A large proportion of patients exhibited reduced exercise capacity, with 63% not reaching 80% of predicted peak VO2. Clinically relevant correlations were noted between the absolute peak values of VO2 versus HR, VO2 versus CO, and VO2 versus LCWi (R = 0.45, p = 0.0005; R = 0.33, p = 0.015; and R = 0.40, p = 0.003, respectively). There was no correlation between AT VO2 and hemodynamic parameters at the AT time point. Furthermore ΔVO2 (peak–AT) correlated with ΔHR (peak–AT), ΔCO (peak–AT) and ΔLCWi (peak–AT) (R = 0.52, p < 0.0001, R = 0.49, p = 0.0001; and R = 0.49, p = 0.0001, respectively). ΔVO2 (peak–rest) correlated with ΔHR (peak–rest), ΔCO (peak–rest), and ΔLCWi (peak–rest) (R = 0.47, p < 0.0001; R = 0.41, p = 0.002; and R = 0.43, p = 0.001, respectively).

Conclusion

ICG is a reliable method of assessing the cardiovascular response to exercise in patients with CAD. Some ICG parameters show definite correlations with parameters of cardiovascular capacity of proven clinical utility, such as peak VO2.

The motivation for physical activity is a predictor of VO2peak and is a useful parameter when determining the need for cardiac rehabilitation in an elderly cardiac population

Background

Exercise-based cardiac rehabilitation (CR) is an essential contributor to a successful recovery for elderly cardiac patients. The motivation for physical activity is a psychological parameter seldom described in secondary prevention, and it is plausible that motivation contributes to the differential effect of CR.

Purpose

To investigate if motivation, measured using the behavioural regulation in an exercise questionnaire (BREQ-2), predicts VO2peak in elderly cardiac patients before and after CR.

Methods

A prospective cohort study of elderly ischemic cardiac patients and patients with valvular disease participating in cardiac rehabilitation was used. Motivation was measured using BREQ-2, which measures five constructs of motivation and a summed score—the relative autonomy index (RAI). VO2peak was measured before and after CR using a cardiopulmonary exercise test (CPET).

Results

Two hundred and three patients performed the baseline tests and initiated CR. One hundred and eighty-two completed CR and comprised the follow-up group. The mean VO2peak was 18 ml/kg/min (SD±5.1). VO2peak increased significantly with increasing motivation, 1.02 (.41–1.62) ml/kg/min pr. SD. Mean improvement from CR was 2.3 ml/kg/min (SD±4.3), the equivalent of a 12% increase. A change in VO2peak after CR was likewise positively associated with increased motivation, .74 (.31–1.17) pr. SD.

Conclusion

The level of motivation predicts VO2peak before CR, and is also able to predict changes in VO2peak following CR. Motivation measured with the BREQ-2 questionnaire can be applied as a screening tool for elderly cardiac patients before they initiate CR to identify patients with need of specific attention.

Very Low-Volume, High-Intensity Interval Training Mitigates Negative Health Impacts of COVID-19 Pandemic-Induced Physical Inactivity

Initially, we aimed to investigate the impact of a one-year worksite low-volume, high-intensity interval training (LOW-HIIT) on cardiometabolic health in 114 sedentary office workers. Due to the COVID-19 pandemic outbreak, LOW-HIIT was discontinued after 6 months and participants were followed up for 6 months to analyze physical activity/exercise behavior and outcome changes during lockdown. Health examinations, including cardiopulmonary exercise testing and the assessment of cardiometabolic markers were performed baseline (T-1), after 6 months (T-2, termination of worksite LOW-HIIT) and 12 months (T-3, follow-up). Cycle ergometer LOW-HIIT (5 × 1 min at 85-95% HRmax) was performed 2×/week. For follow-up analyses, participants were classified into three groups: HIIT-group (continued home-based LOW-HIIT), EX-group (continued other home-based exercises), and NO-EX-group (discontinued LOW-HIIT/exercise). At T-2, VO2max (+1.5 mL/kg/min, p = 0.002), mean arterial blood pressure (MAB, -4 mmHg, p < 0.001), HbA1c (-0.2%, p = 0.005) and self-reported quality of life (QoL, +5 points, p < 0.001) were improved. At T-3, HIIT-group maintained VO2max and QoL and further improved MAB. EX-group maintained MAB and QoL but experienced a VO2max decrease. In NON-EX, VO2max, MAB and QoL deteriorated. We conclude that LOW-HIIT can be considered a promising option to improve cardiometabolic health in real-life conditions and to mitigate physical inactivity-related negative health impacts during lockdowns.

Protein Supplementation Does Not Maximize Adaptations to Low-Volume High-Intensity Interval Training in Sedentary, Healthy Adults: A Placebo-Controlled Double-Blind Randomized Study

There is ample evidence that specific nutritional strategies can enhance adaptions to resistance and endurance training. However, it is still unclear whether post-session protein supplementation may increase the effects of low-volume high-intensity interval training (LOW-HIIT). We examined the impact of LOW-HIIT combined with protein vs. placebo supplementation on cardiometabolic health indices in sedentary healthy individuals. Forty-seven participants (31.1 ± 8.0 yrs) performed cycle ergometer LOW-HIIT (5−10x1 min at 80−95% maximum heart rate) for eight weeks and randomly received double-blinded 40 g of whey protein (PRO-HIIT, N = 24) or an isocaloric placebo (maltodextrin, PLA-HIIT, N = 23) after each session. The maximum oxygen uptake (VO2max, primary outcome) and several secondary cardiometabolic outcomes were determined pre-/post-intervention. VO2max increased in PRO-HIIT (+2.8 mL/kg/min, p = 0.003) and PLA-HIIT (+3.5 mL/kg/min, p < 0.001). Systolic and diastolic blood pressure decreased in PRO-HIIT (−7/3 mmHg, p < 0.05) and PLA-HIIT (−8/5 mmHg, p < 0.001). Gamma glutamyl transferase (−2 U/L, p = 0.003) decreased in PRO-HIIT and alanine aminotransferase (−3 U/L, p = 0.014) in PLA-HIIT. There were no significant between-group differences in any of the outcome changes. In conclusion, LOW-HIIT improved VO2max and other cardiometabolic markers irrespective of the supplementation condition. Post-session protein supplementation does not seem to provide any additional benefit to LOW-HIIT in improving cardiometabolic health in sedentary healthy individuals.